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Public Health, Systems Change, Uncategorized

But for the lottery of birth: Poverty, Racism, and the Permanent Underclass

In Rosa Lee: A Generational Tale of Poverty and Survival, Leon Dash documents the fascinating, disturbing experiences of an extended black urban family struggling to survive the nearly inescapable circumstances of poverty, racism, ignorance, violence and abuse, addiction, and crime in Washington, D.C. during the second half of the twentieth century. Dash, now a professor of journalism at the University of Illinois at Urbana-Champaign, won a Pulitzer Prize for the eight-part series, published daily in the Washington Post between September 18 and 25, 1994, from which this book grew. In it, Dash chronicled the history and experiences of Rosa Lee Cunningham, her eight children, extended family, and generational antecedents. Born among the black debt-slave sharecroppers of North Carolina during the great depression, Rosa Lee’s parents moved their family north in search of better means for survival. Washington, D.C. thus became Rosa’s formative context – the circumstances that were to determine the course of her family’s journey for generations.

On every page of Rosa Lee, one can see the human face and consequences of society’s policies and practices, which themselves represent the prevailing currents of historical struggles. That a society built on ethnic genocide, race-based slavery, and class-based inequality should echo such themes in the present is no surprise. Rather, the surprise in this unflinching biography comes through the honest transcription of Rosa Lee’s experiences within these historical forces, and in the path of their consequences. Rarely do those outside of an oppressed group get sustained exposure to the experiences of those inside. By sharing her story with the author, Rosa Lee has allowed Dash’s reader a rare opportunity to see American society anew through the eyes of those whom the system harmfully, even violently, neglects.

Throughout Rosa Lee, the reader must grapple with the impulse to blame, to judge, and to condemn. The patterns of chronic dysfunctional, criminal, destructive behaviors offend common sensibilities. That so much of the harm befalling Rosa Lee and her family appears self-inflicted seems to demand our moral outrage. But these punitive impulses are as misplaced as they are impotent to change such offending behaviors. Rosa Lee’s story isn’t an aberration. It is part of a larger pattern shared, to varying degrees, by many who also share her circumstances. If our outrage is to find proper or influential targets, we must look to the structural determinants – the structural failures – that constrain such life histories, that marginalize such families, and that impoverish such communities.

In recognition of this imperative – that outputs of a system can’t be effectively or efficiently changed directly, but rather through changing the features and calibrations of the system itself – the new public health seeks to modify the environmental settings and factors that to a great extent determine the individual-level contributors to health outcomes.

For Rosa Lee, her personal attitudes, lack of formal knowledge, self-serving rationalizations, limited marketable skills, and self-destructive lifestyle all undoubtedly contributed to her chronic physical, mental, social, and economic comorbidities. But each of these were formed within a social environment of family, friends, and peers who, through role modeling, negative norms, and absent support, contributed to, or failed to alter, her trajectory.

Likewise, the characteristics of her social networks were themselves constrained by poor, often dangerous physical environments in which they lived, worked, and learned. Lack of availability or access to safe, healthy, productive environments was, in turn, determined by macro-level factors that were, for the most part, so far removed from Rosa Lee’s daily experiences as to be, to her, invisible, yet so influential in her life-course as to have been nearly deterministic.

The legislative, regulatory, policy, and enforcement actions of society’s political, judicial, and economic systems harmed Rosa Lee and her family, as it has and does millions of others before and since. Though such harm is inflicted increasingly more through neglect than malice, it is always because these systems have been designed for the benefit of groups that exclude Rosa Lee and all those who, like her, are defined by such exclusion.

Had Rosa Lee been born in a different place, or had her skin been lighter, or had her education been ensured, or had her socioeconomic status been higher, or had her neighborhoods been safer, or had her family been more dissuasive from crime, or had any or all of a thousand things beyond her control yet influential in her life been different, then Rosa Lee’s story, her despicable behaviors and her heart-wrenching tragedies alike, may well have been different, too.

Rosa Lee’s story, as one in some ways representative of many others, serves as a warning to everyone better served by the system: but for the lottery of birth, any one of us could be Rosa Lee.

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